Septic Shock

Management ofSeptic ShockDr Rajath A.

1Septic ShockSeptic shock- once a uniformly fatal condition with 100% mortality.

Present recovery rates are upto 50%.

Significance: Frequent occurrence and high mortality.

Septic ShockI. Introduction.

II. Pathophysiology

III.Clinical Manifestations

IV.ManagementIntroduction.What is shock?Shock is a state of acute disruption of circulatory function, resulting in insufficiency of tissue perfusion,oxygen utilization and cellular energy producion.

Low BP is NOT sine qua non of shock.Septic ShockI. Introduction.

II. Pathophysiology

III.Clinical Manifestations

IV.ManagementPathophysiologyThe nidus of infection:Localised infections ( otitis, pneumonia, meningitis etc.,)Colonization of mucosal and invasion ( Hib, menigococci)Occult bacteremia ( 3mo to 3 years )Nosocomial : at risk patientsPathophysiologyThe Pathogen:Neonates: GBHS, enterobacteriacae, listeria, Staph aureus, HSV.Infants:Hib, Strep pneumoniae, Staph aureus.Children:Strep pneumoniae, N.meningitidis, S.aureus, enterobacteriacae, Hib.Immunocompromised: Enterobacteriacae,Staph, Pseudomonas, Candida.PathophysiologyPathophysiologyThe agent - host interaction leads toCHAOSPathophysiologyWhat type of shock is septic shock?Septic shock has features of :Hypovolemic shockCardiac shockDistributive shock.

Septic ShockI. Introduction.

II. Pathophysiology

III.Clinical Manifestations

IV.Management10Clinical Manifestations.The Continuum of infection to MODS and Death(Clinical Definitions)Clinical Manifestations.Recognition of Septic Shock:Inflammatory triad-FeverTachycardiaflushed skin Warm ShockHypoperfusionAltered sensorium Urine output>CFTWide pulse pressure.......bounding pulsesClinical Manifestations.HypotensionCold and clammy skinMottlingTachycardia Cold shockCyanosisNarrow pulse pressureHypoxemiaAcidosis.Clinical Manifestations.Staging of Septic Shock:I.Compensated / Preshock / Hyperdynamic

II.Decompensated / Organ hypoperfusion

III. End organ failure / IrreversibleSeptic ShockI. Introduction.

II. Pathophysiology

III.Clinical Manifestations

IV.Management15ManagementPrevention:1.Immunisation

2.Prompt treatment of local infections

3.Hospitalized patient: look out for nidus of infection- IV lines, catheters, E.tubesManagementRecognise septic shock early:Remember- Inflammatory triad Signs of hypoperfusion

Do not wait for the BP to fall !

Lower limit for systolic BP = 70 +( age x 2)Management.Two means of death: 1.Shock.2.Multi organ failure.Aims of treatment:1.Assure perfusion of critical vascular beds. ( cerebral, coronary, renal)2.Rx underlying cause.

ManagementSTEPS1. Prevent / correct hypoxemia: Supplement oxygen 95-100%.2. IV access: peripheral vein.3. If IV access fails: Intraosseous line.4. Fluid resuscitation: 20mL/Kg NS or RLas bolus, repeat upto 60 mL/Kg.End point : Improved perfusion.

ManagementSTEPSImproved perfusion =>a. CFTb. Warmthc. Strong pulsesd. mental statuse. Tachycardiaf. BP (ideal = 90 + age x 2; Min = 70+ age x 2)g. Urine output.ManagementSTEPS5. Establish a 2nd IV line for Dopamine infusion (Draw blood for culture) 6. Administer IV antibiotics2mo: Ceftriaxone or Cefotaxime aloneorAmpicillin + ChloramphenicolManagementSTEPS7. Correct metabolic derangement:Metabolic acidosis.

Hyper or hypoglycemia : always correct hypoglycemia.

ManagementSTEPS8. DIC:Restoration of normovolemia reverses abnormal activation.Component replacement(Goal - Normal PT, PTT, fibrinogen, PC = 40,000 to 1 Lakh/cumm.)a. FFP - most beneficial in early stages. b. Cryo- consider 1 unit/3 units of FFP transfused.c. Platelet concentrateManagementSTEPS9. Recognize and manage organ failure:a. Cardiovascular support:Rate & rythm- correct 02, acidosis, Ca, Mg, K variationsStroke volume - fluid correction & replace lossesIonotrope support.ManagementSTEPS9. Recognize and manage organ failure:b. Renal: Volume replacement Low dose dopamine?diuretic with vol expansion Indications for dialysis:Hyperkalemiarefractory metabolic acidosisAnuria despite diuresisBUN>100mg%ManagementSTEPS9. Recognize and manage organ failure:

c. Respiratory support: Supplement 02, Early intubation and PPV ( PEEP)

d. GI: Antacids, sucralfate, early enteral nutrition.

Monitoring a Child With Septic Shock.Frequent monitoring is MOST IMPORTANT to recognise and Rx complications.1. Pulse5. Urine output.2. BP6. ABG3. Level of consciousness7. PT/PTT/PC4. 02 saturation8. CVPManagement- summary.Five important points1. ABC, supplement 02 always.2. IV or IO access and fluid resuscitation upto 60 mL/Kg.3. Early dopamine infusion @10g/Kg/min4. Empirical antibiotic.5. Frequent monitoring.

References1.Nelson TB of Pediatrics. 16th edn.2.Medical Emergencies in Children- Meharban singh3.PALS: 1997, AAP & AHA.4.PCNA: Intensive Care. 1987.5.TB of Pediatric Critical Care- P.R.Holbrook6.Handbook of PIC- Rogers & Hefaler7.Various Speakers: Critical Care CME, May 2002